Md. health insurers' 'fail first' policies jeopardize patient health

Gene Ransom

Absent from the critical debate in Maryland over how to rein in health care spending has been a serious examination of the dangerous and expensive policies that some Maryland health insurers have enacted in the name of cost containment, and their potentially deleterious impact on patient health.

In the name of controlling costs, some Maryland health insurers have enacted a set of onerous barriers to care that prevent Maryland patients from accessing timely and effective treatment, and place health insurers squarely in the middle of the physician-patient relationship.

One such harmful barrier to care is known as "step therapy" or "fail first," a policy that often requires that patients try and fail on up to five older, less-effective treatments before an insurer will cover the treatment originally prescribed by their doctor. Patients are often forced to try and fail on these treatments even when they have already tried them in the past, and even when their doctor knows the treatments will not work.

For Maryland patients living with a host of serious, often painful conditions including cancer, arthritis or epilepsy, step therapy can mean days, weeks, or months without treatment. This unnecessary delay in care is not only cruel but also jeopardizes patient health and well-being.

Step therapy policies unnecessarily prolong ineffective treatment, prevent Marylanders from immediately receiving access to the life-sustaining treatments their doctors think best, and often exacerbate health problems, allowing manageable conditions to devolve into disease. By forcing patients to undergo cheaper, less-effective treatments that doctors know won't work, insurance companies are driving up their profits on the backs of the sick.

When patients are denied access to treatment, it is not only their physical condition that suffers. Every time a patient is forced to unnecessarily return to the doctor or pharmacist because of an insurer step therapy policy, it can mean additional transportation and child care costs and additional missed work, which in turn drives up costs for Maryland businesses through lost productivity and increased insurance premiums. Step therapy can also drive up the direct costs to the Maryland health care system through unnecessary hospitalization or emergency room visits.

Maryland physicians are frustrated with current insurer policies that prevent doctors from treating their patients as they see fit. A recent survey of MedChi member physicians found that, for 95 percent of Maryland doctors, health insurer protocols like step therapy had a "somewhat" or "very negative" impact on the physician's ability to effectively treat patients.

Many states around the country have already begun to reevaluate health insurer step therapy protocols and their negative impact on patients, with many, including New York, Connecticut and Louisiana, taking legislative action to help curb these insurer abuses. The Maryland General Assembly now has an opportunity to address dangerous health insurer practices that prevent Maryland patients from accessing timely and effective health care.

Among the proposed changes, the bill would limit the duration of step therapy to 30 days and allow doctors to override insurer step therapy policies in specific instances when it is in the best interest of the patient.

Decisions about how to treat patients should remain between the patient and physician, and patients should have reasonably timely access to prescribed procedures and treatments. Advancements in science and medicine are yielding new medications, procedures and therapies that can more effectively treat patients and speed up their recovery. But these therapies will only work if insurers do not force patients to bear the unnecessary physical and emotional burdens of step therapy.

Gene Ransom is the chief executive officer of MedChi, the Maryland State Medical Society. His email is gransom@medchi.org.